Citation Nr: 0900909
Decision Date: 01/09/09 Archive Date: 01/14/09
DOCKET NO. 05-21 187 ) DATE
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On appeal from the
Department of Veterans Affairs Regional Office in Muskogee,
Oklahoma
THE ISSUE
Entitlement to an increased evaluation for post-traumatic
stress disorder (PTSD), currently rated as 50 percent
disabling.
REPRESENTATION
Appellant represented by: The American Legion
ATTORNEY FOR THE BOARD
M. Taylor, Counsel
INTRODUCTION
The appellant served on active duty from June 1980 to April
1986.
This case comes before the Board of Veterans' Appeals (the
Board) on appeal from rating decisions of the Muskogee,
Oklahoma, VA Regional Office (RO).
In a March 2005 notice of disagreement, the appellant
asserted that he had a right ankle disorder related to
service, and that he had headaches, ulcers, diverticulitis,
asthma, acid reflux, a disorder of the legs, and chest pain.
These issues are referred to the agency of original
jurisdiction (AOJ).
In a June 2005 VA Form 9, the appellant requested a Board
hearing. In May 2006, he withdrew the hearing request.
The appeal is REMANDED to the RO via the Appeals Management
Center (AMC), in Washington, DC. VA will notify the
appellant if further action is required.
REMAND
Initially, the Board notes that in December 2008, the
appellant's representative stated that the appellant was in
receipt of Social Security Administration (SSA) disability
benefits. These records have not been associated with the
claims file.
The AOJ has rated the appellant's PTSD with depression as 50
percent disabling under Diagnostic Code 9411. In April 2008,
the appellant stated that his symptoms were worse, and that
the 50 percent evaluation assigned did not reflect the
severity of his PTSD symptoms.
In that regard, the Board notes that under 38 C.F.R. § 4.130,
Diagnostic Code 9411, a 100 percent evaluation is provided
where there is total occupational and social impairment, due
to such symptoms as: gross impairment in thought processes or
communication; persistent delusions or hallucinations;
grossly inappropriate behavior; persistent danger of hurting
self or others; intermittent inability to perform activities
of daily living (including maintenance of minimal personal
hygiene); disorientation to time or place; memory loss for
names of close relatives, own occupation, or own name. A 70
percent evaluation is provided where there is occupational
and social impairment, with deficiencies in most areas, such
as work, school, family relations, judgment, thinking, or
mood, due to such symptoms as: suicidal ideation; obsessional
rituals which interfere with routine activities; speech
intermittently illogical, obscure, or irrelevant; near-
continuous panic or depression affecting the ability to
function independently, appropriately and effectively;
impaired impulse control (such as unprovoked irritability
with periods of violence); spatial disorientation; neglect of
personal appearance or hygiene; difficulty in adapting to
stressful circumstances (including work or a worklike
setting); inability to establish and maintain effective
relationships. A 50 percent evaluation requires occupational
and social impairment with reduced reliability and
productivity due to such symptoms as: flattened affect;
circumstantial, circumlocutory, or stereo-type speech; panic
attacks more than once a week; difficulty in understanding
complex commands; impairment of short and long-term memory;
impaired judgment; impaired abstract thinking; disturbances
of motivation and mood; difficulty in establishing and
maintaining effective work and social relationships.
The Board notes that a February 2004 VA treatment record
reflects a global assessment of function (GAF) rating of 60.
Records, dated in May 2004, note suicide attempts, and a GAF
of 30 was assigned with the best GAF rating in the previous
12 months noted to be 70. An October 2004 record reflects a
GAF rating of 60. On VA examination in February 2005, a GAF
rating of 50 was assigned, suicidal ideation was absent, and
difficulty establishing and maintaining effective work and
social relationships because of an inability to be around
coworkers was noted.
In addition, a March 2005 VA record reflects the appellant's
complaints of hearing voices, and that he was to undergo
mental health treatment at that time. These records of
treatment have not been associated with the claims file.
In this case, the Board finds that further development is
necessary in order to determine the degree of impairment due
to PTSD with depression.
Accordingly, the case is REMANDED for the following action:
1. The AOJ should obtain all SSA records
pertinent to the appellant's claim, to
include any decisions and the medical
records upon which those decisions were
based.
2. The AOJ should obtain any unobtained
VA treatment records relevant to the
appellant's claim that have not been
associated with the claims file. All
records obtained should be associated with
the claims file.
3. The AOJ should schedule the appellant
for a VA psychiatric examination. The
claims file should be made available for
review in conjunction with the examination
and the examiner's attention should be
directed to this remand. The examiner
should note in the report that the claims
file was reviewed. All necessary tests
should be accomplished. The AOJ should
request that the examiner provide an
opinion as to the degree of impairment due
to PTSD with depression, to include an
opinion as to any impact PTSD has on the
appellant's employability. If any
increase in the degree of impairment is
identified during the relevant time
period, an opinion as to the date or dates
of any increase should be reported, to the
extent possible. A complete rationale
should accompany all opinions provided.
4. In light of the above, the claim
should be readjudicated. If the benefits
sought on appeal remain denied, a
supplemental statement of the case should
be issued and the appellant afforded a
reasonable period of time in which to
respond thereto.
The appellant has the right to submit additional evidence and
argument on the matter or matters the Board has remanded.
Kutscherousky v. West, 12 Vet. App. 369 (1999).
This claim must be afforded expeditious treatment. The law
requires that all claims that are remanded by the Board of
Veterans' Appeals or by the United States Court of Appeals
for Veterans Claims for additional development or other
appropriate action must be handled in an expeditious manner.
See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2008).
_________________________________________________
Robert E. Sullivan
Veterans Law Judge, Board of Veterans' Appeals
Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the
Board of Veterans' Appeals is appealable to the United States
Court of Appeals for Veterans Claims. This remand is in the
nature of a preliminary order and does not constitute a
decision of the Board on the merits of your appeal.
38 C.F.R. § 20.1100(b) (2008).